Provider Demographics
NPI:1114527181
Name:BISSONNETTE, COLETTE
Entity Type:Individual
Prefix:
First Name:COLETTE
Middle Name:
Last Name:BISSONNETTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18A LADY SLIPPER TRL
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02813-3415
Mailing Address - Country:US
Mailing Address - Phone:401-465-5734
Mailing Address - Fax:
Practice Address - Street 1:258 POST RD
Practice Address - Street 2:
Practice Address - City:WESTERLY
Practice Address - State:RI
Practice Address - Zip Code:02891-2630
Practice Address - Country:US
Practice Address - Phone:401-322-0793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI32643336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy